HomeMy Public PortalAbout10120 LA ROSA DR_Sewer__ Caeue2a<ea APPLICATION FOR PERM4T
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL 1
• DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
rrOHN A. LAMBIE, Couuty E near ADDRESS _
Cg
D. GRIFFIN. Supt of Ruildivq LOCALITY
NEAflEST '
FOR APPLICANT TO FILL IN CROSS ST.
LEGAL
DESCRIPTION LOT NO. OWNER
BLOCK �/ TRACT MAIL
Z ADDRESS
NO.OF. LDGS.
SIZE OF LOT NOW ON LOT CITY TEL. NO.
USE OF DISTRICT NQ GROUP MAP I PROLE DY
BUILDINGS C`N
�. BK P6
CONTRACT O 1
11 4.07
ADDRESS s CONNECTION ATA
CITY S TEL.NO. U' ION DEPTH
STATE MANHOLE R FE CE U
REGISTRATION NO. l/ f COUNTY _
NO. DESCRIPTION OF WORK FEE 0
HOUSE SEWER CONNECTING TO
PUBLIC SEWER @ $3.00 a� TYPE OF CONNECTION LENGTH FROMSEPTIC TANK. (/
PITS AND/OR DRAEINFGELDIT OR @ $3.00 Y. CURB P.L. M.L. OP.L. J
OVERFLOW SEEPAGE PIT.DRAINFIELD
EXT N.. CESSPOOL.DRYWELL @ $2.00
HOUSE SEWER CONNECTING TO P.C.NO.
PRIVATE DISPOSAL SYSTEM @ $1.00 CO. IMP. N0. JOB N0.
CONNECT ADDITIONAL BLDG.OR TRUNK PERMIT NO. ROAD PERMIT NO
WORK TO HOUSE SEWER @ $1.00
ALTER. REPAIR OR ABANDON HOUSE STATE ENCROACHMENT
SEWER OR DISPO AL SYSTEM @ $I.00 PERMIT NO.
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNER'S PERMIT $ 2 00 CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE dG REIMBURSEMENT FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON-
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS DATE INSPECTOR'S SIGNATURE
TO THE PUBLIC SEWER.
SIGNED THIS DA7 PF 19_ NEW HOUSE SEWER �DV41
OWNER OR LCONNECT ADDITIONAL
OWNERS AGENT BUILDING OR WORK
ADDRESS SEPTIC TANK,SEEP.PITS)
AND/OR DRAINFIELD
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL ❑ DRYWELL ❑
WITH ALL COUNTY ORDINPXCES AND STATE LAWS REGULATING ALTER,REPAIR,SEWER OR
PLUMBING AND SEWERS. ALTER,REPAIR,
DISPOSSEWER OR
1 HEREBY CERTIFY T T I AM PROPERLY REGISTERE AND/OR SEWAGDISCONNECT PLUG AND
EM
LICENSED AS REOUI BY LOS ANGELES OUNTY AND STATE OF ABANDON CT PLUG AND
CALIFORNIA OR TH 1 M THE LEGAL ER QQQFFF ABOVE
WER
DESCRIBED REBID ROPERTY. BACKFILL SEPTIC TANKS ❑
SIGNATURE '
S P. PIT(S) ❑ CESSPOOLS
OF PERMITTE
®t VALIDATION ROBERT A. WOO
DX. Y.o. CAstl SUPERVISING MECHANICAL ENGINEER
7 Ci T
5
CESOS D e.e0 APPLICATION FOR PERMIT - -
xaoe COUNTY OF LOS ANGELES
SEWER-SEWAGE DISPO L
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DMSION BUILDIINSG 0
])OHN A. LAMBIE. Comty Engineer
CASSATf D. GRIFFIN. SuP t of Building LOCALITY
NEAREST
FOR APPLICANT TO FILL. IN CROSS ST. (/ rjr✓
LEGAL
DESCRIPTION LOT NO. OWNER
BLOCK Z!�, TRACT MAIL
ADDRESS
NO.OF BLDG$.
SIZE OF LOT NOW ON LOT CITY TEL.NO.
USE OF
BUILDINGS DISTRICT NO. GROUP MAP PROCE D BY
�K_ /�PG
CONTRACTOR 13- 1L
ADDRESS f— CONNECTION/ ATA
CITY C TEL.N0. O- T TION DEPTH /p
STATE MANXOLE.REFEjtFjFi CET _ UPP
REGISTRATION N0. COUNTY ��/!//I1/l► W
NO. 1 DESCRIPTION OF WUNK FEE i q
7FHOUSE SEWER CONNECTING TO �l
PUBLIC SEWER @ $3.00 TYPE OF CONNECTIONLENGTH FROM
SPTIC TANK.SEEPAGE PI
PETS AND/OR DRAINFIELDT OR @ $300 Y. CURB P.L. M.L.TO P.L.
OVERFLOW SEEPAGE PIT.DRAINFIELD
EXTN..CESSPOOL. DRYWELL @ $2.00
HOUSE SEWER CONNECTING TO P.C.NO.
PRIVATE DISPOSAL SYSTEM @ $1.00 CO. IMP. N0. / JOB N0.
WORK TOT HOUSE(SEWER LOG.OR @ $1 00 TRUNK PERMIT N0. ROAD PERMIT NO.
SEWER OR DISPOSALABANDON SYSTEM HOUSE @ $1.00 STATE ENCROACHMENT
PERMIT N0.
�.� INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNERS PERMIT j CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE ) REIMBURSEMENT FEE
1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON-
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS DATE INSPECTOR'S SIGNATURE
TO THE PUBLIC SEWER.
SIGNED THIS DAY QF 4 19_ NEW HOUSE SEWER
OWNER 01 ✓�(A/ CONNECT ADDITIONAL
OWNERS AGENT BUILDING OR WORK
ADORESSEPTIC TANK,SEEP.PIT(S)
AND/OR DRAINFIELD
1 HEREBY ACKNOWLEDGE THAT IHAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL [I DRYWELL ❑
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER,REPAIR,SEWER OR
PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
1 HEREBY CERTIFY THAT AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REOUIRED B LOS ANGELES COUNTY 4ND STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR THAT M THE LE OWN THE ABOVE
DESCRIBED RESIDENT( 0PERTY. BACKFILL SEPTIC TANKS ❑
SIGNATURE SE P.PIT(S) ❑ CESSPOOL
OF PERMITTE
®r VALIDATIO ROBERT A. WOOD
CK. M.G. u H SUPERVISING MECHANICAL ENGINEER
COT 13 1 c 5 .0